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•%''P , COUNTY OF AN JOAQUIN FRECEIVED <br /> OFFICE OF EMERGENCY SERVICES NOV -2 P012 • <br /> _ 2101 E.Earhart Avenue,Suite 300 <br /> stocktom�5208— -ENVIRONMENTAL <br /> "1k Telephone(209)9038200 N IR OMENTAL <br /> FAX(200)_953;62W___-- <br /> MENT <br /> HAZARDOUS MATERIALS DISCLOSURE-SURVEY– <br /> Please <br /> ISCLOSURESURVEY-- <br /> Please read the information on the reverse side before completing this surveys. A separete survey for each business <br /> name and/or address in San Joaquin County Is required. <br /> Business 1,n1 <br /> Name: wynw a�.a �oSu...J - <br /> Business Owners --- <br /> Name: �p �` Telephone �j`b 3�Z&O('0 <br /> Business <br /> Address: --- <br /> Mailing Ad <br /> Nature of <br /> BI1SIneSS: ( u [?x; s�b(✓,{gxf� �..x"�,�� � n�aY$"'�s'11� .,� <br /> nnj sl ON o`xk , ' eyear? Seethe <br /> nues-floff� <br /> Q2 OYew OW MM rx: p r � us material in a <br /> e time in the year? • <br /> �l A'lr � r ?�y�i �`�' .;r,y e�fyit�'q..3� 3g,��w n .e�"133 'j.. '�` "d ✓d <br /> ,• +. wx. s 4 " r �, $�,'u orb. 3, y� <br /> ilSumer product – <br /> 9j&medical <br /> ga <br /> This businessoperates a farm for purposes of cultivating the soli,raising,or harvesting an <br /> agricultural or horticultural commodity. <br /> Q3. OYes ONo Does your business handle an acutely hazardous material? See definition on reverse side of this <br /> form. <br /> Q4. OYes ONo Is your—business within t,-OW feet of the outer boundary of a school(grades K-42)?-- <br /> I have res ,the Information on this form and underatar�ic my requirements under Chapter 8:95-of the California HeaRtrand <br /> Safety Co . f understand that if I own a facility or property that is used by tenants,that It Is my responsibility to notify the <br /> ter of a requirements which mint a met prior to issuance of a Certificate of OccuRancy orbeglnningof operatkma. <br /> I declare under the penalty of pedu that the information provided_ on this disclosure survey Is true and accurate to the <br /> best of my knowledge. – -- <br /> Owner or Authorized Agent: _ <br /> X Date: <br /> Print Name <br /> X Title: <br /> Signature <br /> F/Appl o"s&HandoutslPlanningAppHeaVons/Btnlnws UCensetReVbed 111441V_. <br /> Page 4 of 6 <br />